| NPI | 1609940329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WY LAT157) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: WY LCSW011) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2007-07-08 |